Forces Shaping Integrated Care Forces Shaping Integrated Care - PDF document

APNA 29th Annual Conference Session 3022: October 30, 2015 Presenters Care Coordination in Integrated Care: Development of a Role for Joyce Shea, DNSc, PMHCNS ‐ BC Psychiatric RNs Fairfield University, CT B. Jamie Stevens, MSN, APRN, PMHNP ‐ BC APNA 29 th Annual Conference Community Health Center, Inc., CT Lake Buena Vista, Florida Amanda Schuh, MS, RN, PMHNP ‐ BC Mayo Clinic Health System, MN Session #3022 Carol Radovich, RN, MSN October 30, 2015 VA Medical Center, West Haven, CT OBJECTIVES Speakers have no conflicts of interest or 1) Describe the historical development of commercial support to disclose for this Integrated Care (IC) and the role of Care presentation. Coordinator. 2) Identify the skills that psychiatric RNs bring to Unless indicated otherwise, all graphics used in the following the role of Care Coordinator. slides were accessed free of charge through the ClipArt program (Microsoft, 2014). 3) Discuss competencies needed by the Care Coordinator in IC and methods for evaluating skills and outcomes. Forces Shaping Integrated Care Forces Shaping Integrated Care • Consumer Voices • Population-Based Needs – Patient Rights – BH Needs of Primary Care Clients – Person-Centered Care – Primary Care Needs of BH Clients – Shared Decision-Making • Disciplinary Perspectives • Policy Development – Medicine, Psychology, Behavioral Health Providers – IOM (2006) – Nursing: Holistic Assessment, Integrated Care – Agency for Healthcare Research & Quality Planning (2008) – Statements on IC by APNA and American Academy of Nursing (2013) – Affordable Care Act (2010) Shea 1

APNA 29th Annual Conference Session 3022: October 30, 2015 Models of Integrated Care Definition of Integrated Care (IC) “The care that results from a practice • Four-Quadrant Clinical Integration team of primary care and behavioral Model health clinicians , working together – National Council for Community Behavioral Healthcare (2009) with patients and families, using a • Vertical and Horizontal Models systematic and cost ‐ effective – Curry & Ham (2010) approach to provide patient ‐ centered care for a defined population.” • Levels of Collaboration Model – Center for Integrated Health Solutions (2013) (AHRQ, 2013, p. 2) Care Coordinator: Psychiatric RNs and the CC Role Emerging Role in IC • Nurses have been suggested as the logical • Shares some features of Case Management services from the 1980’s and 90’s professional to coordinate physical care for people with severe mental illness (Happell, et al., 2011) • That role may be more ancillary than central as a member of the IC team, with varying degrees of autonomy and authority • The educational and clinical preparation of (Lombard et al., 2009) psychiatric ‐ mental health (PMH) nurses has • The more active role of Care Coordinator is required to navigate multiple systems of care and been described as “inherently integrated” and maintain the client’s engagement in care focused on an “understanding of mind ‐ body • Calls for a much more highly personalized and connections” (Delaney, 2015, p. 321) relationship dependent process Skill Sets of the PMH RN Integrated Care in a Federally • Center for Integrated Health Solutions (2014) Qualified Health Center (FQHC) have identified 9 core competencies needed by members of IC teams • These competencies align well with the B. Jamie Stevens, MSN, APRN, PMHNP ‐ BC Standards of Practice for PMH RNs described in Community Health Center, Inc. the Psychiatric ‐ Mental Health Nursing: Scope and Standards of Practice, 2 nd Edition (2014) Waterbury, CT – Includes discussion of specific roles for PMH RNs in Integrated Care Shea 2

APNA 29th Annual Conference Session 3022: October 30, 2015 What is fueling the drive toward care coordination? 1. Fragmentation in health care delivery 2. Health care costs concentrated in small shares of the population with chronic conditions 3. New chronic care needs are emerging (ie. obesity) 4. The chronically ill are most affected by weak care coordination. www.oecd.org/els/health ‐ systems/39791610.pdf, (12 ‐ Dec ‐ 2007), accessed 8/30/15 Definitions Definitions FQHC (Federally Qualified Health Center) – PCMH (Patient Centered Medical Home) 1. Comprehensive care 1. Receive grants under Section 330 of PHSA 2. Patient Centered 2. Receive enhanced reimbursements from Medicare/ Medicaid 3. Coordinated Care 4. Accessible Services 3. Must serve underserved area or population 5. Quality and Safety 4. Provide comprehensive services (https://pcmh.ahrq.gov/page/defining ‐ pcmh, accessed 8/26/2015) 5. Ongoing quality assurance program Safety Net Provider 6. Governing board of directors A mission driven health care agency dedicated to providing care and services to the most vulnerable populations, poor, marginalized, un/der ‐ insured, within a defined service area (www.ncbi.nlm.nih.gov/books/NBK224521/, accessed 8/26/2015) Comprehensive Care (~Integrated Care) in PCMH Function #1: – The primary care medical home is accountable for meeting the large majority of each patient’s physical and mental health care needs, including prevention and wellness, acute care, and chronic care. – Providing comprehensive care requires a team of care providers. This team might include physicians, advanced practice nurses, physician assistants, nurses, pharmacists, nutritionists, social workers, educators, and care coordinators. – Although some medical home practices may bring together large and diverse teams of care providers to meet the needs of their patients, many others, including smaller practices, will build virtual teams linking themselves and their patients to providers and services in their communities. Patients served: >120,000 Shea 3

APNA 29th Annual Conference Session 3022: October 30, 2015 Coordinated Care in PCMH PMH ‐ RN Standards of Practice Standard 1. Assessment Function #2: Standard 6. Evaluation Standard 2. Diagnosis Standard 7. Ethics Standard 3. Outcomes Identification Standard 8. Education Standard 4. Planning Standard 9. EBP and Research Standard 5. Implementation Standard 10. Quality of Practice – The primary care medical home coordinates care across all elements of the a. Coordination of Care broader health care system, including specialty care, hospitals, home health care, Standard 11. Communication b. Health Teaching and Standard 12. Leadership and community services and supports. Promotion Standard 13. Collaboration – Such coordination is particularly critical during transitions between sites of care, c. Consultation Standard 14. Prof. Practice Eval. such as when patients are being discharged from the hospital. d. Prescriptive Authority and Tx Standard 15. Resource Utilization – Medical home practices also excel at building clear and open communication e. Pharm/Biological, and Int. Tx Standard 16. Environmental Health among patients and families, the medical home, and members of the broader care f. Milieu Therapy team. g. Therapeutic Relationship and Counseling h. Psychotherapy Psychiatric Mental Health Nursing Scope and Standards of Practice. 2014. pp iv ‐ v. What is needed to do care Comparison of Care Coordinator coordination? Job Descriptions “Care coordination represents a distinct contribution that Items matched to job function and requires education and dedicated nursing time, separate responsibility: from the day to day tasks in a busy practice.” (Anderson, D, OJIN, 2012) 9 items matched “Coordination is a deliberate cross ‐ cutting action that involves high ‐ quality, caring, and well ‐ informed staff, patients and unpaid caregivers who must work in Items matched to job requirements: partnership together across health and social care 6 items matched settings. For coordination to occur, it must be adequately resourced with efficient systems and services that communicate.” (see handout for complete details) (www.ncbi.nlm.nih.gov/pcm/articles/PMC4008426/…accessed 8/26/2015) How will we know it works? Integrated Care in an Ambulatory Clinic Setting AHRQ Care Coordination Measures Atlas: Appendix IV: Care Coordination Measure Instruments Measure #5: Amanda L. Schuh, MS, RN, PMHNP ‐ BC Care Coordination Measurement Tool Mayo Clinic Health System Measure #6: Mankato, Minnesota Client Perception of Care Coordination http://www.ahrq.gov/sites/default/files/wysiwyg/professionals/prevention ‐ chronic ‐ care/improve/coordination/atlas2014/careap4.pdf (accessed 8/31/15) Shea 4